Friday, July 24, 2009

ACRE Meeting: Welcome to Anger Village

Yesterday, I attended the charter meeting of ACRE (Association of Clinical Researchers and Educators) in Boston. The title of the conference was “Optimizing Value to Patient Care of Industry-Physician Collaboration,” and the schedule called for 23 speakers over a 6 hour period, all in a hot amphitheater crowded with pharmaceutical reps, doctors, reporters, and miscellaneous others.

Obviously, I arrived with a skeptic’s attitude. After all, I had already parodied the organization with this mock blogrenaming ACRE “Academics Craving Reimbursement for Everything.” I was not alone in my difficulty taking the organization seriously. On the pharma gossip website, there was an even more vicious parody, in which the organization is renamed Forum for University Corporate Kickbacks in Education as Determined by University Professors, yielding a more colorful acronym which you can work out on your own.

Why is ACRE so very ripe for satire? Because it consists of rich doctors complaining that they want more money from drug companies, and such an organization lacks any inherent credibility, and seems, frankly, absurd. On the other hand, I like and respect the “two Toms” (Tom Stossel and Tom Sullivan) who formed the organization and I realize that there are some purer motives than greed operating here. That’s why I attended the meeting.

The whole experience felt very much like an anthropological expedition. I took Boston’s Green Line to Harvard’s Brigham and Women’s Hospital (where Dr. Stossel is an esteemed faculty member), a building so massive that the main hallway is called the “Pike.” I was directed by the information clerk to walk down the Pike and take “exit 6” to reach the Bornstein Amphitheater. I arrived 10 minutes late and encountered a small auditorium with steep rows of seats so crowded with pharmaceutical executives and physicians that people were sitting on the steps. I squeezed into a seat in the middle of a row that had been overlooked by the masses, and began my experience of the cultural village that is ACRE.

For the most part, what unreeled over the next 6 hours was an endless succession of smart, accomplished, and furious men (actually, there were three women—two of whom were patients).

Harvard’s dean, Jeffrey Flier, introduced the conference, but his comments must have been exceedingly short, because by 10:10 AM, Dr. Stossel was speaking. As I said, I’ve always liked Tom Stossel, even though we disagree about the value of industry’s use of physicians as marketers and educators. He’s always entertaining and creative. He’s the guy who hatched the evocative term “pharmascolds” to describe people like Senator Grassley and me and plenty others, and in this talk he called the current regulatory environment a “conflict of interest police state.” Though some paint Stossel as an extremist, he is not, and in fact made clear at the outset that the goal of ACRE is not to repeal the recent gift ban and disclosure law passed by the Massachusetts legislature. Rather, he wants ACRE to act as a forum for preventing further restrictions on industry-academic interactions which he feels would be detrimental to medical research and treatment. His heart is in the right place.

Unfortunately, after Stossel’s introductory remarks, the program devolved into a collective middle finger pointed at everybody viewed as the “enemy,” which included government, elite academics (yes, even though the conference was held at Harvard), bloggers, The New York Times, all medical journals, most lawyers, and then I began to lose count.

A major agenda of the speakers was to expunge the term “conflict of interest” from the English language. Dr. Lance Stell, professor of philosophy, said that since there is no “canonical” criteria to distinguish “undue COI” from regular COI, it would be better to just get rid of the term altogether. Other speakers, taking hints from the George W. Bush playbook (eg., it’s “climate change,” not “global warming”), introduced a series of substitutions for conflict of interest, such as “congruence of interests,” “overlapping interests,” “confluence of interests,” or, my favorite, simply “interests.”

It may seem comical, but something more serious than word-play was happening here. The defining problem with inappropriate industry influence in medicine, is, indeed conflicts of interest. When doctors are paid by drug companies to give talks, they are accepting two conflicting and competing incentives: first, deliver the carefully crafted marketing message provided by the drug company, or second, tell the entire truth, which may well include bad things about the drug. Except in rare cases, this ends up not being a convergence, an overlap, or a confluence—it is a conflict.

But industry “interests” were celebrated at this meeting. Culture shock really set in whenDr. Michael Weber, a New York cardiologist with an Australian accent, described his industry ties by saying “I’m proud to say that my list of disclosures is longer than anyone else’s.” Everybody laughed. This was funny. This was clever. Subverting the “politically correct” value system of pharmascolds was a crowd-pleaser in ACRE Village.

Actually, Weber was wrong. University of Texas oncologist Avi Markowitz had him beat in the disclosure department. Markowitz also one-upped his colleagues in the sarcastic fury category. Sarcasm, anger, bitterness, and pride of massive industry involvement are popular emotions among ACRE-nauts. After dismissing the arguments of his critics as “inferential dribble,” Markowitz summarized the opposing side’s argument thusly: “Obviously, if you work with industry you’re evil.” One of his slides encapsulated the baseline attitude of most ACRE-nauts: “#1 Lie in Life: Hi! I’m from the government and I’m here to help you.”

But the eeriest presentation came from one J. Michael Gonzalez-Campoy, an endocrinologist who was flown out on the ACRE-jet from Minnesota. His job was to convince everybody that Minnesota’s 1993 physician payment disclosure law (the first in the nation) was an awful mistake. His tactic, theoretically, was a good one. “The law has been terrible for patients,” he declared, speaking in the ominous tones of a doctor notifying you of grim laboratory results.

“Oh boy,” I thought, pen poised, “finally, some data on the effects of transparency laws on patient outcomes.” But alas, Dr. Gonzalez-Campoy’s evidence base amounted to a single patient, a 73 year old man with severe diabetes. “Do you know what drug he was on?” He asked incredulously. “The cheapest drug money will buy—Glyburide….When I asked my patient why he was on that drug, I was appalled by his answer. He told me that his PCP said it is the most cost-effective drug.” It got worse: the patient had apparently been reading newspaper articles saying bad things about the newer diabetes drugs, like Avandia. The kicker was when he told Dr. Gonzalez-Campoy that “I’ve read that doctors are getting brain-washed by drug companies to prescribe these drugs.” Don’t you see what the Minnesota disclosure law has wrought? Patients getting prescribed generic medications. Patients reading the newspaper. Patients questioning the morals of their physicians.

“Please learn from our mistakes,” Dr. Gonzalez-Campoy, now impassioned, concluded. “Massachusetts should have asked us before they passed their law. They didn’t.”

Thank the Lord!

Tom Sullivan, who put together the event, sounded entertainingly like one of his blog postings—outraged, sarcastic, but with enough actual policy information to keep my attention. Boy, is Sullivan ever pissed at Senator Herb Kohl, who has just announced a senate hearing on industry funding of CME to be held next Wednesday. “Senator Kohl woke up one day last week,” he riffed, “and decided that his staff hadn’t done anything for a while, so he told them to get a hearing together.” I can see why Sullivan is threatened—industry-funded CME is his company Rockpointe’s bread and butter.

There are various awards to be given. Dr. Carey Kimmelstiel, an interventional cardiologist and a professor at my own medical school, Tufts, gets the award for whiny entitlement. His talk was about the value of industry-supported promotional talks. Among the benefits: You learn a lot when you give them, you can network with your colleagues, and your colleagues learn a lot from you. That’s true, but has nothing to do with industry support. It’s possible to give the same talks to colleagues and reap the same benefits without getting a drug company check. It’s actually part of the job of being a medical school professor. But this was merely the irrelevant portion of his talk. The whiny entitled part came when he showed us an email from Doug Drachman, a Mass General cardiologist who has been organizing quarterly meetings of Boston interventional cardiologists to talk about interesting cases. His email broke the bad news that because of the Massachusetts law banning industry from taking doctors out to fancy dinners, these meetings are being postponed. Dr. Kimmelstiel was outraged. Look at the unintended consequences of the gift ban law—now cardiologists can no longer meet with another. That’s rich. Interventional cardiologists are some of the highest salaried professionals in the world, and yet they refuse to pay for their own dinners four times a year? That’s why I call the organization Academics Craving Reimbursement for Everything.

Oddly, the best and most convincing presentation was also the shortest. Dr. Jeffrey Garber, chief of endocrinology at Harvard Vanguard, profiled the American Association of Clinical Endocrinologists, of which he is the president. He outlined all the good things the organization is doing to educate primary care doctors and the public about diabetes and thyroid disease, all of it funded by industry. His point was that without industry money his organization couldn’t do all these great things. Probably true, though there are other ways for doctors to learn this information, like grand rounds, journals, and meetings that they might have to pay for themselves.

Henry Black, the President of the American Society of Hypertension, basically made the same case as Garber, arguing that his entire organization would cease to exist without drug company money. Unfortunately, Dr. Black got the day’s award for the most mangled slide. In a tirade against a recent JAMA paper recommending that medical societies cease industry ties, he started insulting the individual authors, saying, essentially, that most of them are washed up has-beens. Unfortunately, he had Dr. James Scully listed as the “president of the Josiah Macy Foundation,” rather than his actual job, which is the executive director of the APA. I didn’t point it out, because he was just working up steam and was beginning to froth at the mouth.

It was the quintessential ACRE moment: fury, self-righteousness, and getting everything a little bit wrong.

21 comments:

You obviously want all patients and key opinion leaders to suffer merciless fates under a totalitarian regime of pharmascolds, you tree-hugging liberal varmint. At least that's what I imagine would be the ACRE response. Maybe a new motto for the organization: "Only losers buy their own meals!"

Thank you, Danny, for this run-down on the ACRE meeting. Your description confirmed that there is no beef in their complaints.

Listening to these partisans, I am reminded of the great sociologist Jane Jacobs. In discussing the ethics of the guardian tradition, which includes medicine, and the ethics of the commercial tradition she has one of her protagonists say, “There are many fine points to medical ethics, and some difficult puzzles, but the most rudimentary morality is the line between the guardian and commercial (traditions). It’s as crucial that physicians understand it as it is that lawyers recognize that when they go into guardian service they can’t morally also be in service to clients seeking to influence legislation or regulatory decisions.” [Systems of Survival, Random House 1992]

The angry members of ACRE are right to be angry, but their anger is misdirected. They should be angry with themselves for allowing a Wild West ethic to prevail, to the extent that ethical outliers were unchecked. Academic institutions and professional societies failed to do their jobs of reining in these outliers. Senator Grassley had to do it for them. Now all will pay a price in the form of increased external regulation. You did it to yourselves, folks.

I don't think there can be a reasonable solution right now because neither side of the argument seems to want to behave like an adult. I've seen the self-righteous anger of well paid KOLs at having anyone dare to limit their activities and it's a bit much. By the same token your report is a bit over the top as well - "frothing at the mouth"? Not very helpful. I don't think that demonizing regulators or making fun of academics with industry ties is very helpful.

Maybe you could have used your position as a former industry fund recipient, putatively unbiased provider of CME, faculty at Tufts, and Harvard (MGH) trainee to provide a bit more reasoned insight.

Here is the question that bothers me about the entire situation. When do we start blaming the practicing doctors for being led around by there noses? Now they apparently will make an prescription they are told to at a lecture or from any company who would have incsribed their name on a pen. Is it really goingto lead to better healthcare if they are going to treating people out of fear because they are now being monitored on the web?

I really don't know but would love for someone to try and tackle the problem rather than just fight for their agenda.

"rich doctors complaining that they want more money from drug companies"

As a patient, I wish I had some way of finding out about my doctors' ties to industry. I get wary when all my doctors deny that diet and nutrition can work, and they proceed to fill out numerous prescriptions that I don't want because they have already caused me to have major adverse effects.

"The angry members of ACRE are right to be angry, but their anger is misdirected."

"Now all will pay a price in the form of increased external regulation. You did it to yourselves, folks."

I suspect that while they may be angry. The purpose of ACRE is to minimize any regulation, oversight or limits that will be forthcoming. This is always part of the dance. 2 steps forward and 1 step back. The pharmaceutical industry and KOLs will still be well ahead in terms of COIs of where they were a number of years ago. Although the more I look the more I find that this has been going on for decades so maybe it's just become more widespread and blatent.

The answer to all this has been called for by many papers and editorials in journals in recent years: Full registration of all drug trials and publication of drug trial methodology and raw results on regulated websites.

Richard Smith, editor for 25 years at the BMJ goes as far to say journals should cease publishing drug trials from researchers and sponsoring Pharma companies. What journals should publish is independent reviews of the raw results all of us can view online.

The effect of this would then be to have an academic literature that could be trusted. Professors and experts in a particular field could be "academic detailers" - they should be anyway. Those wanting to give pharma sponsored talks simply get seen for what they are - possibly biased, possibly not - but you don't know. Thus there is an A-grade independent source and a B-grade pharma related source for information. Everyone knows which is which.

At risk of spam I will just mention again www.healthyskepticism.org/documents/Antipsychotics.php and look to "AstraZeneca Investigator Initiated Trials" near bottom of page and then the link to Richard Smith's article in PLoS Medicine.

Dr C -- You deride Dr. Gonzalez-Campoy’s evidence base: a single patient, a 73 year old man with severe diabetes whose PCP had placed on the most cost-effective medication. He seemed to feel better about this decision after reading that “doctors are getting brain-washed by drug companies to prescribe these [newer] drugs.”

Yet, recently Consumer Reports, that great arbiter of vacuum sucking and psychopharmacological efficacy, warned parents to turn down their physicians' offer of free sample ADHD medications, lest they get "hooked" on unnecessarily costly new medications." This was the new lede on a press release that rehashed last year's report on ADHD medications. It as stupid then, and it's still stupid.

Instead of newer formulations with smother, sustained delivery systems, such as Concerta, Strattera, Vyvanse, and Daytrana -- the choices that have revolutionized ADHD treatment for millions -- they should stick to dexedrine and methylphenidate. (You know, the choices foreigners in NHS systems are stuck with and whose high side effect profile leads to non-compliance and non-adherence.)

Moreover, says CR, they should use generics! Read more about this here http://tinyurl.com/nmulcl

When even Consumer Reports warns readers that their physicians must have impure motives if they offer samples, and when it announces that generic dexedrine is as good as Vyvanse or Concerta, we've gone far beyond Pharmascolding. We've stepped back into the Dark Ages.

Patients will suffer, and we will directly attribute their misery to equally reckless, egotistical vigilantes with no common sense and no compassion.

Anonymous wrote: "Here is the question that bothers me about the entire situation. When do we start blaming the practicing doctors for being led around by there noses?"

AMEN! Seems physicians have a long history of scapegoating their internal collective problems.

When we can't get hospital physicians to wash their hands and when they rebel at ditching their long-sleeved germ-laden lab coats (because they convey authority, presumably), the problem goes so, so much deeper than pharma reps with cleavage.

Read Lisa Sanders' excellent new book, Every Patient Tells a Story, to learn, for example, why physicians no longer perform hands-on physical exams. Will we blame this on the equipment manufacturers? Where does it end?

I am glad you attended and could relate what went on at the ACRE meeting. Paying attention to language, as you note, is important. Ownership of the issues is often transferred insidiously by these means.

The absence of serious evidence offered for the benefits to medicine and patient care of industry participation even at this most high and sanctimonious occasion shows how its justification boils down to greed, dependence, and delusion or ignorance.

Greed requires little comment, except to note that it refers to both pecuniary and career greed, since it is difficult to climb in academic medicine today without such ties.

By dependence I mean that many facets of medical practice--research funding, association membership, grand rounds honorariums, journal and conference scientific programming, conveniences for individual practices all the way up to public health administration budgets and more--have come to rely on industry funding for a range of services, many of which are no longer fundable by other means precisely because industry has been happily picking up the tab. Remove industry grease from every aspect of contemporary medicine, and the entire machinery might nearly grind to a halt. (As with other addictions, the patient will have to be weaned slowly.)

By delusion/ignorance I mean that those who still trust that big pharma prioritizes bringing safe and effective medicines to the public, or that the FDA acts as an arbiter of innovation and a watchdog for safety, are either in thrall to their drug reps and key opinion leaders, or oblivious to the torrent of reports and evidences of marketing malfeasance that clearly describe the mainstream and not the fringe of pharmaceutical industry practices today.

There are many who have affirmed that conflicts of interest (COIs) are ethically dubious. The ACRE reactionaries can achieve little more than self-parody on that point. But focussing on this will not fix the problem, since ethical opprobrium is apparently a weak motivator for reform. Instead, we must lead the medical profession to recognize that the lattice of COIs across all areas of medicine and medical research has evolved into a cross-dependence that is deleterious to the profession's autonomy, its scientific progress, and its trustworthiness among the public--evident even from the anecdote related by Mr. Gonzalez-Campoy himself.

Ms. Pera: Please provide a non-Pharma funded link to research that demonstates Consumer Reports is wrong. In other words, a link that shows that Concerta, Strattera, Vyvanse, and Daytrana are more efficacious than generics.

"they should stick to dexedrine and methylphenidate. (You know, the choices foreigners in NHS systems are stuck with and whose high side effect profile leads to non-compliance and non-adherence.)"

As a foreigner stuck in Australia's mix of private/public but universal single payer supported health system - I have no problems prescribing Strattera, Concerta or Ritalin-LA where compliance, side effect or efficacy issues occur with the short-acting forms of the stimulants. When I worked in the UK all 3 were available on the NHS also. In both countries subsidies on prescribed medications meant the cost was either nil or minimal to the patient.

The USA's health system costs in per-capita and % of GDP around 50% to 100% more than any of the other 19 OECD countries including Australia and the UK (which all have some sort of single payer based universal cover for their citizens) but somehow still fails to provide cover to nearly 50 million citizens.

The efficiencies of a single payer system vs inefficiencies of a multiple health insurer system where (more pervasive than in foreign countries) corporate for-profit motives siphon off some of the money - presumably have something to do with this.

So (although this is off topic of ACRE) I'm curious as to what Dr Pera's comment about foreigners is supposed to mean?

However I also say "Amen" to Dr Pera's comment about physicians being "led around by their noses" and her analogy to hand-washing by physicians. In fact this analogy is also used by Dr Peter Mansfield from Healthy Skepticism in an article you can read at: www.abc.net.au/unleashed/stories/s2579404.htm

First, thank you for "believing" in ADHD and treating it knowledgeably in Australia.

Perhaps you're being facetious by calling me "Dr. Pera." Though I'm not a physician or scientist, I've had to become an expert in order to eke out evidence-based strategies from our highly dysfunctional mental health system. And I've done that by studying the literature, reading many books, attending many conferences, etc. Most importantly, I've talked with thousands of people with ADHD about their experiences.

Having gained that knowledge, I've gone on to help others on the learning curve.

My information about people with ADHD in other countries comes from an international support group that I lead for the partners of adults with ADHD (they are often the first to connect the behavior to the condition and initiate evaluation, etc.). It also comes from recent speaking engagements in Canada and the UK, where I've listened closely to treatment experiences.

Reports from Australia are heavily focused on lamenting Dexedrine being a first-line treatment. While you apparently watch for side effects, many other clinicians aren't so astute. If the people I hear from have the option of moving up to smoother formulations, they don't know about it.

In the UK, standard of care is getting better but it's still an inordinate trial to not only find an ADHD specialist but also get an appointment. There is much resistance and too many obstacles.

That's downright cruel when you consider this is a condition that inhibits initiation, motivation, follow-through, and decision making, not to mention having one hope in hell that life can actually improve.

The people in the UK who are getting decent care are paying out of pocket. Many others simply do without. Same thing for people here without insurance or who depend on the VA.

I hope that answers your question.

Please note, Anonymous: I don't respond to people who don't reveal their identities and who ask me to do their work for them. Do it yourself.

Ms. Pera: My comment was not intended to be offensive. But your rejoinder obviously speaks for itself. To wit: "Please note, Anonymous: I don't respond to people who don't reveal their identities and who ask me to do their work for them. Do it yourself."

Well, why should I do the heavy lifting for you? I was just asking because we have had to indure years of Big Pharma telling us that the second generation anti-psychotics were "better" than the old guard meds like Haldol. But guess what? RESEARCH in the US and UK reveal the opposite. The "old line" agents are cheaper and just as good as the second generation agents! With less side effects! Just wondered if this was true of the ADHD meds. No need to adopt a defensive posture -- unless, of course, you don't really know what you are blogging about.

I wasn't being facetious, just making an unfounded assumption that you were an MD.

I'm not saying the NHS in the UK is perfect, there are long waiting lists, but at least there is universal cover and the UK as a whole (in a 2003 OECD report) pays around 8% of GDP towards health, whilst the USA paid over 15% of GDP to health.

Access to timely care is probably much quicker in Australia than the UK and we (in 2003) paid 9.2% of GDP towards health for (like all other 18 OECD countries except the USA) universal cover.

My point is that the USA's current health system needs major reform. Not alone in stating that! Also a lot of money must be being siphoned off or wasted.

As to being a "believer" in ADHD, the short answer is "yes" but in my opinion it is overdiagnosed.

The longer answer is "not quite" and without fully explaining myself I would just say ADHD like some other psychiatric diagnoses is a syndromal description - what causes inattention-impulsivity-hyperactivity etc in one person may be quite different to what causes a similar picture in another. More important than a diagnostic label is a "case formulation" - a paragraph or two explanation of all the interacting causal factors.

The situation is complicated by perhaps a majority (one older study says 70%) of the general population respond with improved concentration on psychostimulants. In that sense they are performance enhancing drugs. Uni students commonly use/abuse them at exam times. Romania during Cseucescu's communist regime had (according to a Romanian psychiatrist who now lives in the UK) the academic children and children of the middle classes on Ritalin in vast numbers - apparently as he wanted Romania to be the clever country - not just win an innordinate number of Olympic medals with athletes fed anabolic steroids through their youth. An interesting story which adds a twist to the whole ADHD debate, don't know how true but my colleague was quite clear about it.

There are some children in my clinical experience who benefit greatly from the stimulants. But the MTA study seems to suggest relying on medication alone isn't that great in the long run.

When I worked in Wales in the UK the CAMHS service there had a brilliant assessment service for presumptive ADHD cases. It involved, teacher and parent questionnaires and interview, psychometric IQ assessment, observations of child in classroom and playground and home all by a psychologist, then extended interview of family, child, parents with psychiatrist. Time devoted to getting the diagnostic formulation right at start was seen as both best practice and time saving in the longer run. But I know that service was more unique than usual in the UK.

Dexamphetamine (Dexedrine) is no longer the only psychostimulant formulation on Australia's pharmaceutical benefits scheme - the other formulations mentioned above have been added in recent years. So those you spoke to were perhaps correct at the time, but things have since changed. The other formulations were always available on a more expensive private script once a drug company put them on the market.

There's much in your post to respond to, Peter, but of course this isn't the place for it. I welcome oyour comments at my blog http://www.ADHDRollerCoaster.org

Two points, though, which are of general interest to this Carlat Psychiatry blog:

1. MTA study: Unfortunately, one renegade researcher (Bill Pelham, apparently eager to gain funding/notereity for his ADHD Summer Camp program or simply being addle-brained) did much harm in misinterpreting the results.

BOTTOM LINE: The medication stops working because they stop taking it! OR, they take it in sub-par community settings, not according to clinical standards of the study. THIS IS NO SURPRISE!

Jim Swanson, whom I respect greatly, did not help matters in sort of reinforcing Pelham's point - but for an entirely different reason. (Sometimes scientists really shouldn't talk to the media without an interpreter.) IMHO, Swanson is a brilliant big-picture thinker who has devoted many years to ADHD research. He has stated that what we're doing isn't working, and he is correct. We cannot rely on physicians in the community, overall, to provide the standard of care required for effective ADHD treatment.

Moreover, we cannot continue to treat children without treating their parents. ADHD is 76 percent heritable. Children with ADHD are 24 times more likely than other children to have a mother with ADHD. All children need stability and structure, but children with ADHD need this in double-doses. And when they live in a home that is disorganized and chaotic, where there is financial instability and often much conflict, their symptoms are exacerbated.

2. Stimulants and the general population. It is no secret that humans respond to stimulation. Our brains could engage in nothing without it.

And it's no secret that ADHD is, to put it loosely, Extreme Human Syndrome. In other words, it takes more extreme stimulation to kick those neurons into gear than it does for the "average" person. Humans are on a continuum with their need for stimulation. So, why wouldn't most people respond to stimulants? The key is the degree required.

It's also no secret that the average person with average stimulation requirements does a disservice to mind and body alike by abusing stimulants. It's not a sustainable practice. Yet, for people with ADHD who do need the stimulants, they suffer no ill physical effects, even after years of taking them daily. In fact, their health often improves, including sleeping and eating habits as well as exercise levels. They also often quit drinking, smoking, and seeking stimulation in other unhealthy activities.

On many college campuses, there is a stigma against taking ADHD medication. It's seen as offering an unfair advantage, so many who need it won't take it. Or, they'll take it only at crunch time (because that's a long-established college tradition, not ADHD, right?). And many who are undiagnosed use it as a study aid. It's a complicated picture. No easy platitudes.

The program in Wales sounds great. If they screened the parents, too, that would be perfection.

Finally, I think if the Romanian Brain Trust experiment had worked, we would have heard about it. ;-)

Anonymous -- re-read your comment. It speaks for itself. Moreover, if you accept those studies uncritically, I hope to heck you aren't a prescribing physician.

P.S. Peter, the MTA researchers have never concluded that medication alone is what's needed. Multi-modal treatment has always been key.

Russell Barkley gave a tremendous lecture on ADHD at the CADDAC conference in Toronto, in May. The video should be available on their site soon and sold as a fund-raising DVD for this Canadian non-profit devoted to ADHD education and support. Highly recommended viewing.

Ms. Pera: I have re-read your comments as well and I thank God that YOU are not a prescribing physician. I simply asked for non-Pharma references to your assertions about the "new" ADHD medications supremacy over the "old" agents. And all I got was a pithy response about how I should research the issue. But one who makes a thesis should support it with research citations-- which you failed to do. And with all due respect, the research backing my thesis -- that older anti-psychotic agents are just as effective with less cost and fewer side effects as compared to the newer atypicals-- has been reported in the American Journal of Psychiatry, the Journal of the American Medical Association and the premier Britsh medical journal Lancet. Perhaps it is YOU that needs to study the relevant research.

While this blog needs no cheerleading from me, I must commend the gracious and professional commentary by both Gina Pera and Peter Parry. Your insights, which I read on a Monday morning, bode well for a good week. Thank you and cheers, j.